Version July 2025
Fluoroquinolones have been associated with disabling and potentially irreversible serious adverse reactions that have occurred together, including: tendinopathy and tendon rupture, peripheral neuropathy, and CNS effects. Discontinue ciprofloxacin immediately and avoid the use of fluoroquinolones in patients who experience any of these serious adverse reactions. Because fluoroquinolones have been associated with serious adverse reactions, reserve ciprofloxacin for use in patients who have no alternative treatment options for the following indications: acute exacerbation of chronic bronchitis, acute sinusitis, and acute uncomplicated cystitis.
Fluoroquinolones may exacerbate muscle weakness in patients with myasthenia gravis. Avoid ciprofloxacin in patients with known history of myasthenia gravis.
Anthrax: Note: Consult public health officials for event-specific recommendations.
Inhalational (postexposure prophylaxis):
Oral: Immediate release: 500 mg every 12 hours.
IV: 400 mg every 12 hours.
Duration of therapy: Duration depends on anthrax vaccine status and series completion, age, immune status, and pregnancy/breastfeeding status. For those who have not previously received an anthrax vaccine, duration ranges from 42 to 60 days (Ref). Some experts favor longer durations of prophylaxis (eg, total of 3 to 4 months) for patients who are immunocompromised or remain unvaccinated (Ref).
Note: Administer anthrax vaccine to exposed individuals (Ref).
Cutaneous, without meningitis, treatment (off-label use): Oral: Immediate release: 500 mg every 12 hours for 7 to 10 days after naturally acquired infection. After aerosol exposure, transition from treatment to postexposure prophylaxis; combined duration should total 42 to 60 days, depending on vaccine status, pregnancy/breastfeeding status, and immunocompetence (Ref).
Systemic, including meningitis, treatment (off-label use): IV: 400 mg every 8 hours, in combination with other appropriate agents, for ≥2 weeks; duration may be shortened and patient transitioned to oral therapy based on response and clinical judgement (Ref). Some experts suggest ≥3 weeks of IV combination therapy for patients with meningitis (Ref). After aerosol exposure, transition patients who are immunocompromised from treatment to postexposure prophylaxis; combined duration should total 60 days. Note: Administer antitoxin in addition to antibiotics for systemic anthrax (Ref).
Bite wound infection, prophylaxis or treatment (animal and human bites) (alternative agent) (off-label use): Note: Use in combination with an appropriate agent for anaerobes (Ref).
Oral: Immediate release: 500 to 750 mg twice daily (Ref).
IV: 400 mg every 12 hours (Ref).
Duration of therapy: 3 to 5 days for prophylaxis (Ref); for established infection, continue for 1 to 2 days after resolution, typically 5 to 14 days total, although deep or complicated infections may require a longer duration (Ref).
Bronchiectasis, acute exacerbation (off-label use): Oral: 500 to 750 mg twice daily for up to 14 days (Ref).
Cholera (Vibrio cholerae) (alternative agent) (off-label use): Oral: Immediate release: 1 g as a single dose (Ref)
Chronic obstructive pulmonary disease, acute exacerbation (off-label use): Note: Some experts reserve for patients with risk factors for poor outcomes (eg, ≥65 years of age, FEV1 <50% predicted, frequent exacerbations, significant comorbidities) who are at risk of Pseudomonas infection (Ref).
Oral: Immediate release: 750 mg twice daily (Ref), although 500 mg twice daily may be reasonable in the absence of P. aeruginosa (Ref). Duration is 5 to 7 days (Ref).
Diabetic foot infection (off-label use): Note: When used as empiric therapy, ciprofloxacin should be used in combination with other appropriate agents.
Mild to moderate infection: Oral: Immediate release: 500 mg every 12 hours (750 mg every 12 hours if Pseudomonas aeruginosa is suspected) (Ref).
Moderate to severe infection: IV: 400 mg every 12 hours (400 mg every 8 hours if P. aeruginosa is suspected) (Ref).
Diarrhea, infectious:
Salmonella gastroenteritis:
Nontyphoidal, severe (nonbacteremic) illness or any severity in patients at high risk for invasive disease:
Patients with HIV:
Oral: Immediate release: 500 to 750 mg every 12 hours (Ref).
IV: 400 mg every 12 hours (Ref).
Duration: 7 to 14 days in patients with a CD4 count ≥200 cells/mm3 or 2 to 6 weeks in patients with a CD4 count <200 cells/mm3 (Ref).
Patients without HIV: Oral: Immediate release: 500 mg twice daily for 3 to 14 days (Ref).
Nontyphoidal bloodstream infection:
Oral: Immediate release: 500 to 750 mg every 12 hours (Ref).
IV: 400 mg every 12 hours (Ref).
Duration: 10 to 14 days for patients who are immunocompetent; 14 days for patients with HIV and CD4 count ≥200 cells/mm3. Patients who are immunosuppressed (eg, patients with HIV with a CD4 count <200 cells/mm3) and those with an extraintestinal focus of infection require a longer duration of treatment (eg, weeks to months) (Ref).
Typhoid fever (Salmonella typhi and paratyphi): Severe disease or mild to moderate infection in patients at high risk of developing invasive disease. Note: Use only if MIC ≤0.06 mcg/mL because the incidence of fluoroquinolone-resistant strains is increasing (Ref).
Oral: Immediate release: 500 mg every 12 hours for 7 to 10 days (Ref).
IV: 400 mg every 12 hours for 7 to 10 days (Ref).
Shigella gastroenteritis: Note: Use only if MIC is <0.12 mcg/mL (Ref).
Patients with HIV:
Oral: Immediate release: 500 to 750 mg every 12 hours (Ref).
IV: 400 mg every 12 hours (Ref).
Duration: 7 to 10 days. For bacteremia, continue for ≥14 days; for recurrent infection (particularly when CD4 <200 cells/mm3), may extend therapy for up to 6 weeks (Ref).
Patients without HIV:
Oral: Immediate release: 500 mg twice daily or 750 mg once daily for 3 days. For patients with Shigella dysenteriae type 1 infection, extend the duration to 5 to 7 days; for bacteremia, continue for 14 days (Ref).
Endocarditis, treatment (off-label use):
HACEK organisms (alternative agent):
Oral: Immediate release: 500 or 750 mg every 12 hours for 4 weeks (native valve) or 6 weeks (prosthetic valve) (Ref).
IV: 400 mg every 8 to 12 hours for 4 weeks (native valve) or 6 weeks (prosthetic valve) (Ref).
S. aureus, methicillin-susceptible, oral step-down therapy (alternative agent): Note: Data are limited; not first-line therapy. Some experts suggest oral antibiotics as an alternative for patients who inject drugs and are not able to complete IV standard of care therapy (Ref).
Oral: Immediate release: 750 mg every 12 hours in combination with rifampin for a total duration, including initial IV therapy, of 6 weeks (Ref).
Intra-abdominal infection, mild to moderate, community acquired in patients without risk factors for resistance or treatment failure:
Note: Empiric oral regimens may be appropriate for patients with mild to moderate infection. Other patients may be switched from IV to oral therapy when clinically improved and able to tolerate an oral diet (Ref).
Cholecystitis, acute:
Note: The addition of anaerobic therapy (eg, metronidazole) is recommended if biliary-enteric anastomosis is present (Ref).
IV: 400 mg every 12 hours.
or
Oral: Immediate release: 500 mg every 12 hours.
Duration: Continue for 1 day after gallbladder removal or until clinical resolution in patients managed nonoperatively (Ref).
Other intra-abdominal infections (eg, appendicitis, diverticulitis, intra-abdominal abscess):
Note: For acute diverticulitis, some experts suggest deferring antibiotics in otherwise healthy immunocompetent patients with mild disease; however, data on this approach in outpatients are limited (Ref).
IV: 400 mg every 12 hours in combination with metronidazole.
or
Oral: Immediate release: 500 mg every 12 hours in combination with metronidazole.
Duration: Total duration of therapy (which may include transition to oral antibiotics) is for 4 to 5 days following adequate source control (Ref). For diverticulitis or uncomplicated appendicitis managed without intervention, duration is 10 to 14 days (Ref); for perforated appendicitis managed with laparoscopic appendectomy, 2 to 4 days may be sufficient (Ref).
Meningitis, bacterial (community-acquired or health care-associated) (alternative agent) (off-label use): IV: 400 mg every 8 to 12 hours; for empiric therapy, must be used in combination with other appropriate agents (Ref)
Meningococcal meningitis prophylaxis (off-label use):
Note: Ciprofloxacin should not be used when ≥2 cases of ciprofloxacin-resistant meningococcal disease cases have been reported and cases that are caused by ciprofloxacin-resistant strains account for ≥20% of all cases reported in a local catchment area during a 12-month period (Ref).
Oral: Immediate release: 500 mg as a single dose (Ref).
Neutropenia (chemotherapy-induced), antibacterial prophylaxis in high-risk patients anticipated to have an ANC ≤100 cells/mm3 for >7 days (off-label use): Oral: Immediate release: 500 to 750 mg twice daily (Ref); some clinicians will provide antibacterial prophylaxis if ANC is anticipated to be <500 cells/mm3 for >7 days (Ref). For hematopoietic cell transplant recipients, begin at the time of stem cell infusion and continue until recovery of neutropenia or until initiation of empiric antibiotic therapy for neutropenic fever (Ref).
Neutropenic fever, low-risk cancer patients (empiric therapy) (off-label use): Oral: Immediate release: 750 mg every 12 hours (Ref) in combination with amoxicillin and clavulanate; continue until fever and neutropenia have resolved. Note: Avoid in patients who have received fluoroquinolone prophylaxis. Administer first dose in the health care setting (after blood cultures are drawn); observe patient for ≥4 hours before discharge (Ref).
Osteomyelitis:
Oral:
Treatment: Immediate release: 500 to 750 mg every 12 hours; when treating P. aeruginosa, 750 mg every 12 hours for ≥6 weeks (Ref).
Chronic suppression in presence of retained infected orthopedic hardware: Immediate release: 250 to 500 mg every 12 hours (Ref).
IV: 400 mg every 12 hours; when treating P. aeruginosa, 400 mg every 8 hours for ≥6 weeks (Ref).
Plague (Yersinia pestis):
Note: Consult public health officials for event-specific recommendations.
Postexposure prophylaxis: Oral: Immediate release: 500 to 750 mg every 12 hours (for patients who are pregnant, 500 mg every 8 hours or 750 mg every 12 hours) for 7 days (Ref).
Treatment, excluding meningitis:
Oral: Immediate release: 750 mg every 12 hours; for patients who are pregnant, 500 mg every 8 hours (Ref).
IV: 400 mg every 8 hours (Ref).
Duration of therapy: 7 to 14 days and for at least a few days after clinical resolution (Ref).
Pneumonia, as a component of empiric therapy or pathogen-specific therapy for Pseudomonas aeruginosa in hospitalized patients : Note: For empiric therapy, use in combination with other appropriate agents (Ref).
Oral: Immediate release: 750 mg every 12 hours (Ref).
IV: 400 mg every 8 hours (Ref).
Duration of therapy: Varies based on disease severity and response to therapy; treatment is typically given for 7 days (Ref).
Prostatitis:
Acute bacterial prostatitis:
Oral: Immediate release: 500 mg every 12 hours for 2 to 4 weeks (Ref).
IV: 400 mg every 12 hours for 2 to 4 weeks (Ref).
Chronic bacterial prostatitis:
Oral: Immediate release: 500 mg every 12 hours for 4 to 6 weeks (Ref).
IV: 400 mg every 12 hours for 4 to 6 weeks (Ref).
Prosthetic joint infection (off-label use): Note: Alternative agent for certain pathogens.
Treatment:
Gram-negative bacilli:
Oral: Immediate release: 750 mg twice daily (Ref).
IV: 400 mg every 12 hours (Ref); some experts prefer 400 mg every 8 hours for infections caused by P. aeruginosa (Ref).
Staphylococcus aureus, oral continuation therapy (following pathogen-specific IV therapy in patients undergoing 1-stage exchange or debridement with retention of prosthesis):
Oral: Immediate release: 500 to 750 mg twice daily (Ref) in combination with rifampin; total treatment duration is a minimum of 3 months, depending on patient-specific factors (Ref).
Chronic suppressive therapy for P. aeruginosa: Oral: Immediate release: 250 to 500 mg twice daily (Ref).
Rhinosinusitis, acute bacterial (alternative agent):
Note: In uncomplicated acute bacterial rhinosinusitis, initial observation and symptom management without antibiotic therapy is appropriate in most patients. Reserve antibiotic therapy for poor follow-up or lack of improvement over the observation period (Ref). Given S. pneumoniae resistance, ciprofloxacin is not recommended for the empiric treatment of acute bacterial rhinosinusitis (Ref). Additionally, the FDA recommends ciprofloxacin be reserved for patients who have no alternative treatment options in the treatment of acute rhinosinusitis (Ref).
Oral: Immediate release: 500 mg twice daily (manufacturer’s labeling); typical duration is 5 to 7 days (Ref).
IV: 400 mg every 12 hours (Ref); typical duration is 5 to 7 days (Ref).
Septic arthritis (alternative agent): Note: Use in combination with a second anti-pseudomonal agent for initial treatment in patients with increased risk for mortality or resistant pathogens (Ref).
Oral: Immediate release: 750 mg every 12 hours (Ref).
IV: 400 mg every 8 to 12 hours (Ref).
Duration of therapy: 3 to 4 weeks (in the absence of osteomyelitis), including oral step-down therapy (Ref).
Sexually transmitted infections:
Chancroid (alternative agent) (off-label use): Oral: Immediate release: 500 mg twice daily for 3 days (Ref).
Gonorrhea, uncomplicated (infection of the cervix, rectum, urethra): Note: Not recommended for empiric treatment of gonorrhea due to widespread resistance (Ref). Confirm ciprofloxacin susceptibility prior to use (Ref).
Oral: 500 mg as a single dose (Ref). Give in combination with treatment for chlamydia if it has not been excluded (Ref).
Spontaneous bacterial peritonitis, prophylaxis (alternative agent) (off-label use):
Note: For secondary prophylaxis in patients with prior spontaneous bacterial peritonitis (SBP) and primary prophylaxis in patients at high risk for SBP (eg, low ascites protein [<1.5 g/dL] with advanced liver failure or impaired kidney function). Some experts also use for prophylaxis during hospitalization in patients with cirrhosis and either acute GI bleeding or ascites protein <1 g/dL (Ref).
Oral: Immediate release: 500 mg once daily (Ref). For patients with cirrhosis and acute GI bleeding, some experts use 500 mg twice daily following, or as an alternative to, parenteral prophylaxis, for a total antibiotic duration of 7 days (Ref).
Surgical prophylaxis (off-label use): Note: Use in combination with other appropriate agents may be warranted (procedure-dependent) (Ref).
IV (alternative agent): 400 mg within 120 minutes prior to surgical incision (Ref).
Oral: Immediate release: 500 mg within 120 minutes prior to surgical incision. Note: Reserve use for high-risk cystoscopy (eg, urine culture positive, preoperative catheter, or placement of prosthetic material), cystoscopy with manipulation (eg, transrectal prostate biopsy), or upper GU tract instrumentation. Due to increasing resistance among urinary pathogens, review local sensitivity prior to use (Ref).
Tularemia (Francisella tularensis) (off-label use): Note: Consult public health officials for event-specific recommendations.
Mild disease: Oral: Immediate release: 500 or 750 mg twice daily for 10 to 14 days (Ref).
Postexposure prophylaxis: Oral: Immediate release: 500 or 750 mg twice daily for 14 days (Ref).
Urinary tract infection:
Cystitis, acute uncomplicated or acute simple cystitis (infection limited to the bladder without signs/symptoms of upper tract, prostate, or systemic infection) (alternative agent):
Note: Use is discouraged due to safety concerns and increasing resistance; reserve for those who have no alternative treatment options (Ref). However, for men who have severe symptoms or there is concern for early prostate involvement, some experts prefer fluoroquinolones (Ref).
Oral: Immediate release: 250 mg every 12 hours (Ref); for treatment of resistant gram-negative infection (eg, extended-spectrum beta-lactamase [ESBL]-producing Enterobacterales, AmpC beta-lactamase-producing Enterobacterales), some experts recommend 500 mg every 12 hours (Ref).
Oral: Extended release [Canadian product]: 500 mg every 24 hours.
Duration: 3 days (females) (Ref) or 5 days (males) (Ref).
Urinary tract infection, complicated (including pyelonephritis):
Note: If the prevalence of fluoroquinolone resistance is >10%, an initial dose of a long-acting parenteral antimicrobial (eg, ceftriaxone) followed by oral therapy is recommended for outpatients (Ref).
Oral: Immediate release: 500 mg every 12 hours for 5 to 7 days (Ref); for treatment of resistant gram-negative infection (eg, ESBL-producing Enterobacterales, AmpC beta-lactamase-producing Enterobacterales), some experts recommend 750 mg every 12 hours (Ref).
Oral: Extended release [Canadian product]: 1 g every 24 hours for 5 to 7 days.
IV (inpatient): 400 mg every 12 hours for a total of 5 to 7 days (Ref); for treatment of resistant gram-negative infection (eg, ESBL-producing Enterobacterales, AmpC beta-lactamase-producing Enterobacterales), some experts recommend 400 mg every 8 hours (Ref).
Missed dose:
Oral, immediate release: Administer as soon as possible if ≥6 hours until next scheduled dose, otherwise, wait until next scheduled dose; do not double doses to compensate for missed dose.
Oral, extended release [Canadian product]: Administer as soon as possible if ≥8 hours until next scheduled dose, otherwise, wait until next scheduled dose; do not double doses to compensate for missed dose.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Altered kidney function:
|
CrCl (mL/minute) |
Oral, immediate release |
Oral, extended release [Canadian product] |
IV |
|---|---|---|---|
|
aExpert opinion derived from manufacturer's labeling, Heintz 2009, Mrhar 1990. bFor severe infections, 750 mg may be administered at the intervals noted above. cConsider administering a loading dose of 400 mg × 1 if utilizing 200 mg every 24 hours. dConsider administering a loading dose of 500 mg × 1 if utilizing 250 mg every 24 hours. eMinimally dialyzable (<10%); when scheduled dose falls on a dialysis day, administer post dialysis. | |||
|
CrCl >50 to <130 |
500 to 750 mg every 12 hours |
1 g every 24 hours |
400 mg every 8 to 12 hours |
|
CrCl 30 to 50 |
250 to 500 mg every 12 hoursb |
1 g every 24 hours |
400 mg every 8 to 12 hours |
|
CrCl <30 |
500 mg every 24 hoursb |
500 mg every 24 hours |
200c to 400 mg every 12 to 24 hours |
|
Hemodialysis, intermittent (thrice weekly)e |
250d to 500 mg every 24 hoursb |
500 mg every 24 hours |
200c to 400 mg every 24 hours |
|
Peritoneal dialysis |
250d to 500 mg every 24 hoursb |
500 mg every 24 hours |
200c to 400 mg every 24 hours |
Augmented renal clearance (measured urinary CrCl ≥130 mL/minute/1.73 m2): Augmented renal clearance (ARC) is a condition that occurs in certain critically ill patients without organ dysfunction and with normal serum creatinine concentrations. Young patients (<55 years of age) admitted post-trauma or major surgery are at highest risk for ARC, as well as those with sepsis, burns, or hematologic malignancies. An 8- to 24-hour measured urinary CrCl is necessary to identify these patients (Ref).
IV: 400 mg every 8 hours when organism minimum inhibitory concentration (MIC) ≤0.125 mg/L. Monte Carlo simulations suggest a dose of 600 mg every 8 hours may be required to achieve pharmacodynamic goals for organisms with MICs >0.125 mg/L (Ref); monitor closely, especially with prolonged courses, or utilize another agent (Ref).
CRRT: Drug clearance is dependent on the effluent flow rate, filter type, and method of renal replacement. Recommendations are based on high-flux dialyzers and effluent flow rates of 20 to 25 mL/kg/hour (or ~1,500 to 3,000 mL/hour) unless otherwise noted. Appropriate dosing requires consideration of adequate drug concentrations (eg, site of infection) and consideration of initial loading doses. Close monitoring of response and adverse reactions (eg, neurotoxicity) due to drug accumulation is important.
IV: 200 to 400 mg every 8 to 12 hours (Ref). Note: Utilize 400 mg every 8 hours only in severe infections or when difficult-to-treat organisms (MIC ≥0.5 mg/L) are suspected or confirmed (Ref); monitor closely.
Oral, immediate release: 250 to 750 mg every 12 hours (expert opinion inferred from relative IV clearance).
PIRRT (eg, sustained, low-efficiency diafiltration): Drug clearance is dependent on the effluent flow rate, filter type, and method of renal replacement. Appropriate dosing requires consideration of adequate drug concentrations (eg, site of infection) and consideration of initial loading doses. Close monitoring of response and adverse reactions (eg, neurotoxicity) due to drug accumulation is important. Dosing based on Monte Carlo simulations of 8- to 10-hour treatments with 4 to 5 L/hour flow rates.
IV: 400 mg every 12 hours assuming MIC susceptibility breakpoint ≤0.5 mg/L (Ref).
Oral, immediate release: 500 mg every 12 hours (administer after PIRRT) (expert opinion inferred from relative IV clearance).
The hepatic dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Matt Harris, PharmD, MHS, BCPS, FAST, FCCP; Jeong Park, PharmD, MS, BCTXP, FCCP, FAST; Arun Jesudian, MD; Sasan Sakiani, MD.
Initial or dose titration in patients with preexisting liver cirrhosis or dosage adjustment in patients with chronic, worsening hepatic function during treatment:
Child-Turcotte-Pugh class A through C: IV, Oral: No dosage adjustment necessary (Ref).
Acute worsening of hepatic function (eg, requiring hospitalization): No dosage adjustment necessary; however, consider discontinuation of ciprofloxacin therapy in patients with suspected ciprofloxacin-induced liver injury unless the benefits outweigh the risks (Ref).
Refer to adult dosing.
(For additional information see "Ciprofloxacin (systemic): Pediatric drug information")
Dosage guidance:
Dosage form information: Oral liquid products are available in 2 concentrations (ie, 50 mg/mL and 100 mg/mL); verify product selection; use caution.
Clinical considerations: Fluoroquinolones should not typically be used as first-line therapy due to their adverse effect profile and risk of development of bacterial resistance. Only use in situations when there is no safe and effective substitute available (eg, drug resistance, allergy) or when oral fluoroquinolone therapy provides a reasonable alternative to parenteral therapy (Ref).
General dosing:
Infants, Children, and Adolescents:
Oral: Immediate release: 15 mg/kg/dose every 12 hours; usual maximum dose: 500 mg/dose (Ref).
IV: 10 mg/kg/dose every 8 to 12 hours; maximum dose: 400 mg/dose (Ref).
Anthrax: Note: Consult public health officials for event-specific recommendations.
Postexposure prophylaxis (inhalational exposure): Infants, Children, and Adolescents:
Oral: Immediate release: 15 mg/kg/dose every 12 hours for 60 days; maximum dose: 500 mg/dose (Ref).
IV: 10 mg/kg/dose every 12 hours for 60 days; maximum dose: 400 mg/dose.
Cutaneous, without systemic involvement; treatment: Infants, Children, and Adolescents:
Oral: Immediate release: 15 mg/kg/dose every 12 hours; maximum dose: 500 mg/dose. For naturally acquired infection, treat for 7 to 10 days; for a biological weapon-related event, treat for up to 60 days (Ref).
Severe anthrax (eg, anthrax meningitis, inhalational anthrax, head or neck lesions, cutaneous anthrax with systemic involvement); treatment:
Note: Administer as part of an appropriate combination regimen for ≥2 to 3 weeks and until patient is clinically stable. After completion of therapy, if exposure was due to spore inhalation, initiate antimicrobial prophylaxis to complete an antimicrobial course of 60 days from onset of illness (Ref).
Infants, Children, and Adolescents:
Initial parenteral treatment: IV: 10 mg/kg/dose every 8 hours; maximum dose: 400 mg/dose; continue until clinical criteria for stability are met (Ref).
Oral step-down therapy: Oral: Immediate release: 15 mg/kg/dose every 12 hours; maximum dose: 500 mg/dose (Ref).
Campylobacteriosis: Limited data available:
Diarrhea: Note: Antibiotics are typically not required for uncomplicated enteritis in otherwise healthy patients; when antibiotics are indicated, other agents (eg, azithromycin) may be preferred due to widespread fluoroquinolone resistance in Campylobacter spp (Ref).
Infants ≥6 months, Children, and Adolescents: Oral: Immediate release: 10 to 15 mg/kg/dose every 12 hours; maximum dose: 750 mg/dose. Usual duration: 3 to 5 days; patients with HIV may require 7 to 10 days of therapy (Ref).
Bacteremia in HIV-infected Adolescents: Note: Treat for ≥14 days for bacteremia, and 2 to 6 weeks for recurrent disease; consider use in combination with an aminoglycoside (Ref).
Oral: Immediate release: Adolescents: 500 to 750 mg every 12 hours (Ref).
IV: Adolescents: 400 mg every 12 hours (Ref).
Chancroid (Haemophilus ducreyi): Limited data available: Children weighing ≥45 kg and Adolescents: Oral: Immediate release: 500 mg every 12 hours for 3 days (Ref).
Cholera (Vibrio cholerae) (alternative agent): Limited data available:
Single-dose regimen: Infants, Children, and Adolescents: Oral: Immediate release: 20 mg/kg as a single dose; maximum dose: 1,000 mg/dose (Ref).
Three-day regimen: Infants, Children, and Adolescents: Oral: Immediate release: 15 mg/kg/dose twice daily for 3 days; maximum dose: 500 mg/dose (Ref).
Cystic fibrosis, acute pulmonary exacerbation: Limited data available:
Children and Adolescents: Note: Treatment duration varies and is dependent on patient-specific factors, including response to therapy; typical duration is 10 to 21 days (Ref).
Oral: Immediate release: 20 mg/kg/dose every 12 hours; usual maximum dose: 750 mg/dose; higher maximum dose of 1,000 mg/dose has been described (Ref).
IV: 10 mg/kg/dose every 8 hours; maximum dose: 400 mg/dose (Ref).
Endocarditis, culture negative: Limited data available: Note: Administer as part of an appropriate combination regimen. In patients with native valve infection, treat for 4 to 6 weeks; in patients with late prosthetic valve infection, treat for 6 weeks (Ref).
Children and Adolescents:
Oral: Immediate release: 10 to 15 mg/kg/dose every 12 hours; maximum dose: 750 mg/dose (Ref).
IV: 10 to 15 mg/kg/dose every 12 hours; maximum dose: 400 mg/dose (Ref).
Exit-site or tunnel infection, peritoneal dialysis catheter: Limited data available: Infants, Children, and Adolescents: Oral: Immediate release: 10 to 15 mg/kg/dose every 24 hours; maximum dose: 500 mg/dose (Ref).
Intra-abdominal infection (alternative therapy): Limited data available: Note: May be considered in lower-risk patients with community-acquired infection when beta-lactams cannot be tolerated; local susceptibility patterns should be considered (Ref).
Infants, Children, and Adolescents: IV: 10 to 15 mg/kg/dose every 12 hours; maximum dose: 400 mg/dose. Treatment duration varies based on specific source of infection, success of source control procedures, and clinical response; a total duration of 5 days is typically recommended (Ref).
Meningitis or ventriculitis, health care associated (alternative agent): Limited data available:
Infants, Children, and Adolescents: IV: 10 mg/kg/dose every 8 hours or 15 mg/kg/dose every 12 hours; maximum dose: 400 mg/dose. Duration of treatment varies based on isolated pathogen, cerebrospinal fluid studies, and clinical presentation; treat gram-negative pathogens for at least 10 to 14 days (Ref).
Meningococcal disease (Neisseria meningitidis), chemoprophylaxis after close contact with a patient with invasive disease: Limited data available:
Infants, Children, and Adolescents: Oral: Immediate release: 20 mg/kg as a single dose; maximum dose: 500 mg/dose (Ref).
Mycobacterium avium complex infection, disseminated disease, treatment (alternative agent): Limited data available:
Infants and Children with HIV: Oral: Immediate release: 10 to 15 mg/kg/dose every 12 hours as part of an appropriate combination regimen for ≥12 months; maximum dose: 750 mg/dose (Ref).
Plague (Yersinia pestis) infection: Note: Consult public health officials for event-specific recommendations.
Postexposure prophylaxis: Infants, Children, and Adolescents: Oral: Immediate release: 15 mg/kg/dose every 12 hours for 7 days; maximum dose: 750 mg/dose (Ref).
Treatment, excluding meningitis: Note: Treat for a total of 10 to 14 days; therapy may be extended if clinical resolution not observed (eg, ongoing fever) (Ref).
Infants, Children, and Adolescents (Ref):
Oral: Immediate release: 15 mg/kg/dose every 8 to 12 hours; maximum daily dose: 1,500 mg/day.
IV: 10 mg/kg/dose every 8 to 12 hours; maximum dose: 400 mg/dose; may transition to oral therapy if appropriate once clinically improved.
Pneumonia, community acquired, due to Haemophilus influenzae (alternative agent): Limited data available:
Infants >3 months and Children: IV: 15 mg/kg/dose every 12 hours; maximum dose: 400 mg/dose. Transition to oral therapy when able for a total duration of 5 to 10 days (Ref).
Salmonella species infection, nontyphoidal, treatment: Limited data available:
Adolescents with HIV: Note: For gastroenteritis without bacteremia, treat for 7 to 14 days; if CD4 is <200 cells/mm3, treat for 2 to 6 weeks, especially if illness was severe initially. For gastroenteritis with bacteremia, treat for ≥14 days, and longer if bacteremia persists or infection is complicated, or if CD4 is <200 cells/mm3 (up to 6 weeks) (Ref).
Oral: Immediate release: 500 to 750 mg every 12 hours (Ref).
IV: 400 mg every 12 hours (Ref).
Shigella diarrhea: Limited data available: Note: Only use if MIC is <0.12 mg/dL (Ref).
Infants, Children, and Adolescents: Oral: Immediate release: 15 mg/kg/dose every 12 hours for 3 to 5 days; maximum dose: 500 mg/dose (Ref). Adolescents with HIV may require a longer duration (ie, 7 to 10 days) and higher doses up to 750 mg every 12 hours (Ref).
Surgical prophylaxis: Children and Adolescents: IV: 10 mg/kg as a single dose within 120 minutes prior to surgical incision; maximum dose: 400 mg/dose (Ref).
Tularemia (Francisella tularensis) (alternative agent): Limited data available: Note: Consult public health officials for event-specific recommendations.
Infants, Children, and Adolescents:
Treatment, mild disease:
IV: 15 mg/kg/dose every 12 hours for 10 to 14 days; maximum dose: 400 mg/dose (Ref).
Oral: Immediate release: 15 mg/kg/dose every 12 hours for 10 to 14 days; maximum dose: 500 mg/dose (Ref).
Postexposure prophylaxis: Oral: Immediate release: 15 mg/kg/dose twice daily for 14 days; maximum dose: 500 mg/dose (Ref).
Urinary tract infection:
Cystitis, acute uncomplicated:
Children and Adolescents: Limited data available: Oral: Immediate release: 10 to 20 mg/kg/dose every 12 hours; maximum dose: 750 mg/dose (Ref). Treat for 3 to 5 days; children <2 years of age may require a longer course (eg, 7 days) (Ref).
Complicated (including pyelonephritis): Note: Treat for a total of 6 to 10 days; children <2 years of age may require a longer course (eg, 7 to 14 days) (Ref).
Oral: Immediate release: Children and Adolescents: 10 to 20 mg/kg/dose every 12 hours; maximum dose: 750 mg/dose (Ref). Note: When treating Pseudomonas aeruginosa, doses of 20 mg/kg/dose every 12 hours are recommended based on pharmacokinetic modeling (Ref).
IV: Children and Adolescents: 6 to 10 mg/kg/dose every 8 hours; maximum dose: 400 mg/dose (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Infants, Children, and Adolescents:
IV, Oral (immediate release): There are no dosage adjustments provided in the manufacturer's labeling; however, the following guidelines have been used by some clinicians (Ref):
GFR ≥30 mL/minute/1.73 m2: No dosage adjustment necessary.
GFR 10 to 29 mL/minute/1.73 m2: 10 to 15 mg/kg/dose every 18 hours.
GFR <10 mL/minute/1.73 m2: 10 to 15 mg/kg/dose every 24 hours.
Hemodialysis/peritoneal dialysis (PD) (after dialysis on dialysis days): Minimally dialyzable (<10%): 10 to 15 mg/kg/dose every 24 hours.
CRRT: 10 to 15 mg/kg/dose every 12 hours.
There are no dosage adjustments provided in manufacturer's labeling; use with caution in severe impairment.
Fluoroquinolones have been associated with aortic aneurysm and aortic dissection with risk of aortic aneurysm higher than aortic dissection (Ref). Risk of aortic dissection may be lower with ciprofloxacin and moxifloxacin than with levofloxacin (Ref).
Mechanism: Time-related; up-regulation of matrix metalloproteinases in the aortic wall results in degradation of collagen and elastin in the extracellular matrix, increasing the risk for aortic aneurysm (Ref). Downregulation of extracellular matrix proteins (notably Lysyl oxidase) results in destabilization of collagen-elastin crosslinking, increasing risk for aortic dissection (Ref).
Onset: Varied; typically within 60 days after initiation (Ref).
Risk factors:
• Longer duration of therapy (Ref)
• Older patients
• History of aortic aneurysm
• High risk for aortic aneurysm or dissection (eg, aortic wall defect, hypertension) (Ref)
Arthropathy, or joint disease, has been observed following treatment with fluoroquinolone antibiotics, including ciprofloxacin (Ref). In an international, multicenter, randomized trial of ~700 pediatric patients (ciprofloxacin versus comparator), more patients in the ciprofloxacin group experienced musculoskeletal events both within 6 weeks and 1 year of follow-up. Arthropathy and arthralgias appear to resolve after discontinuation of treatment with no long-term sequelae (Ref). Though the true incidence is unknown, arthropathy and arthralgia are considered infrequent, but potentially serious adverse reactions.
Mechanism: Unknown; several hypotheses have been proposed, including inhibition of mitochondrial DNA synthesis in immature chondrocytes, direct toxic effect of fluoride on cartilage, magnesium chelation and subsequent deficiency in cartilage, and defective proteoglycan and procollagen synthesis with decreased incorporation of tritiated thymidine by chondrocytes (Ref).
Onset: Varied; may occur within the first day of initiation or months following discontinuation (Ref).
Risk factors:
• Higher doses (Ref)
• Prolonged exposure (Ref)
Fluoroquinolones have been associated with a range of neurologic and psychiatric effects, ranging from dizziness and restlessness to toxic psychosis (Ref). Additional reactions include confusion, agitation, insomnia, and drowsiness. More severe reactions include delusions, hallucinations, suicidal ideation, suicidal tendencies, and toxic psychosis. Neuroexcitation may include seizure in some patients (Ref).
Mechanism: GABA binding disruption, NMDA binding alterations, and increased excitatory neurotransmitters (Ref). Mitochondrial dysfunction has been hypothesized to contribute (Ref).
Onset: Varied; neuroexcitatory phenomena generally occur in the first week of therapy, often after 2 to 3 days (Ref).
Risk factors:
• Older adults (Ref)
• Kidney impairment with unadjusted or higher doses (Ref)
• Concurrent therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with enhanced neuroexcitation (Ref)
• Concurrent theophylline (Ref)
• History of seizures, seizure disorders, CNS disorders, or concurrent therapy with medications known to lower seizure threshold may increase risk of seizures (Ref)
• History of or risk factor for mental illness (eg, depression)
Clostridioides difficile infection (CDI), including Clostridioides difficile-associated diarrhea and Clostridioides difficile colitis, has been reported (Ref).
Mechanism: Dose- and time-related; related to cumulative antibiotic exposure. Fluoroquinolones may cause disruption of the intestinal microbiota resulting in the overgrowth of pathogens, such as C. difficile (Ref).
Onset: Varied; may start on the first day of antibiotic therapy or up to 3 months postantibiotic (Ref).
Risk factors:
• Antibiotic exposure (highest risk factor) (Ref)
• Type of antibiotic (fluoroquinolones among the highest risk) (Ref)
• Long durations in a hospital or other health care setting (recent or current) (Ref)
• Older adults (Ref)
• Immunocompromised conditions (Ref)
• A serious underlying condition (Ref)
• GI surgery/manipulation (Ref)
• Antiulcer medications (eg, proton pump inhibitors and H2 blockers) (Ref)
• Chemotherapy (Ref)
Hyperglycemia and hypoglycemia have been associated with the use of fluoroquinolones, including ciprofloxacin (Ref)
Mechanism: Increase in insulin release via blockade of adenosine triphosphate-sensitive potassium channels in the pancreatic beta cells, but the significance at clinical concentrations has been questioned (Ref). Additionally, effects on gluconeogenesis, glucose transport (via expression of GLUT-1), and mitochondrial dysfunction have been implicated (Ref).
Onset: Varied; corresponds to the initiation of therapy but may be delayed by 2 to 3 days. Events requiring emergent care or hospitalization occurred between day 3 and day 10 of therapy (Ref).
Risk factors:
• Patients with diabetes or chronic kidney disease (Ref)
• Concurrent hypoglycemic agents or steroids (Ref)
Ciprofloxacin may cause hepatotoxicity; cholestatic, hepatocellular, and mixed patterns are represented in reported clinical presentations (Ref). Hepatic necrosis, life-threatening hepatic failure, and fatal cases have occurred.
Mechanism: Immunologic reactions account for many events; direct toxicity related to mitochondrial dysfunction and increased oxidative stress may also be responsible for some reactions (Ref).
Onset: Varied; acute liver injury may occur in a range of 1 to 39 days.
Risk factors:
• Most fatal events occurred in patients >55 years of age
Hypersensitivity reactions include anaphylaxis, nonimmune anaphylaxis, and delayed cutaneous reactions.
Delayed cutaneous reactions include severe dermatologic reactions, acute generalized exanthematous pustulosis, drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome, and toxic epidermal necrolysis (Ref). Less severe reactions include nonbullous and bullous fixed drug eruption (Ref).
Immunologically mediated organ-specific reactions include pneumonitis, vasculitis, pancreatitis, interstitial nephritis, hemolytic anemia, thrombocytopenia, and some cases of hepatitis (Ref).
Mechanism: Nonimmune anaphylaxis results from binding directly to specific receptors (MGPRX2) on mast cells and basophils, causing direct stimulation of histamine release (and other mediators) (Ref). Importantly, these cases may occur without prior exposure. In other cases, anaphylaxis may be mediated by IgE, formed with prior exposure to the drug (Ref).
Delayed reactions are mediated by activated T-cells. Chemical activation of fluoroquinolones was not required for immune reactions to occur, which implies direct activation (pharmacologic interaction) without covalent binding to host proteins/hapten formation (Ref). Ciprofloxacin forms metabolites, but haptens have not been characterized to date.
Onset: Anaphylaxis (nonimmune and immune): Rapid; may occur within an hour of administration (Ref). Other reactions, particularly various maculopapular cutaneous reactions, or organ-specific reactions: Varied; occur after days to weeks of therapy (Ref).
Risk factors:
• Nonimmune anaphylaxis may be dose- and/or infusion rate-related (concentration-related) (Ref)
Fluoroquinolones, including ciprofloxacin, may cause an exacerbation of myasthenia gravis. Disease exacerbations vary in severity from muscular weakness to severe compromise (myasthenic crisis characterized by acute respiratory failure) (Ref).
Mechanism: Neuromuscular blockade is the most frequently cited mechanism, although alterations in mitochondrial energy production has also been suggested as a contributing mechanism (Ref).
Onset: Rapid; within hours of the initiation (Ref)
Risk factors:
• Patients with myasthenia gravis (diagnosed and undiagnosed) (Ref)
Fluoroquinolones have been associated with peripheral neuropathy and other effects, including axonal neuropathy and Guillain-Barré syndrome (GBS) (Ref). Fluoroquinolones are associated with many types of disturbances of special senses, including several case reports indicating a very slow recovery and/or permanent state of disability (Ref).
Mechanism: Mitochondrial effects related to reactive oxygen species and apoptotic changes (Ref).
Onset: Varied; may present as early as the first day of therapy (Ref).
Risk factors:
• Males (Ref)
• Older adults (>60 years of age) (Ref)
• Duration of therapy (Ref)
• Type 1 diabetes may also be a risk factor (data are limited) (Ref)
• History of peripheral neuropathy
Phototoxicity/skin photosensitivity account for a proportion of the overall cutaneous adverse reactions (Ref). Published reports with ciprofloxacin are limited; may be more common with other fluoroquinolones (Ref).
Mechanism: Non-dose-related; immunologic. Reactive intermediates are generated by ultraviolet exposure and attach to proteins of Langerhans cells, triggering immune reactions (Ref).
Onset: Rapid; in a study with ofloxacin, occurred within 24 hours of initiation and sun exposure (Ref).
Risk factors:
• Duration and intensity of sun exposure
• Cystic fibrosis (Ref)
• Prior phototoxic reaction to another fluoroquinolone (Ref)
Fluoroquinolones may be associated with prolonged QT interval on ECG and ventricular arrhythmias, such as torsades de pointes (TdP). Ciprofloxacin may have a lower risk than other fluoroquinolones, particularly moxifloxacin (Ref). Change in QTc from baseline for moxifloxacin was found to be +16.34 to 17.83 ms, while the change with ciprofloxacin was +2.27 to 4.93 ms (Ref).
Mechanism: May alter the rapid delayed rectifier potassium current, resulting in prolonged repolarization (Ref). Prolonged repolarization can alter action potentials in cardiac cells and promote arrhythmogenic activity (Ref).
Onset: Varied; effect is concentration-dependent, initially observed at supra-therapeutic doses (Ref). High dose or accumulation may influence timing/concentrations.
Risk factors:
Drug-induced QTc prolongation/TdP (in general):
• Females (Ref)
• Age >65 years (Ref)
• Structural heart disease (eg, history of myocardial infarction or heart failure with reduced ejection fraction) (Ref)
• History of drug-induced TdP (Ref)
• Genetic defects of cardiac ion channels (Ref)
• Congenital long QT syndrome (Ref)
• History of drug-induced TdP (Ref)
• Baseline QT interval prolongation (eg, >500 msec) or lengthening of the QTc by ≥60 msec (Ref)
• Electrolyte disturbances (eg, hypocalcemia, hypokalemia, hypomagnesemia) (Ref)
• Bradycardia (Ref)
• Hepatic impairment (Ref)
• Kidney impairment (Ref)
• Loop diuretic use (Ref)
• Sepsis (Ref)
• Concurrent administration of multiple medications (≥2) that prolong the QT interval or increase drug interactions that increase serum drug concentrations of QT prolonging medications (Ref)
Ciprofloxacin may cause tendinopathy or rupture of tendon; Achilles is most commonly cited, but inflammation/rupture of many other tendons (including hand, rotator cuff, biceps, and thumb) has been reported (Ref).
Mechanism: Dose- and time-related; upregulation of matrix metalloproteinases (MMPs) degrade collagen and elastin in the extracellular matrix (Ref). May also have a direct effect on the viability of chondrocytes and tenocytes responsible for collagen synthesis, due to generation of reactive oxygen species, caspase activation and apoptosis (Ref).
Onset: Varied; per the manufacturer's labeling, tendinopathy or tendon rupture may occur within hours or days of initiation or may be delayed for several months after discontinuation.
Risk factors:
• Age >60 years (Ref)
• Corticosteroid therapy (Ref)
• Kidney failure (Ref)
• Diabetes mellitus (Ref)
• Previous tendon disorders (eg, rheumatoid arthritis) (Ref)
• Solid organ transplant recipients (Ref)
• Strenuous physical activity (Ref)
• Longer duration of therapy and higher dosages (Ref)
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%: Neuromuscular & skeletal: Musculoskeletal signs and symptoms (children: 9% to 22%)
1% to 10%:
Dermatologic: Skin rash (1% to 2%)
Gastrointestinal: Abdominal pain (children: 3%; adults: <1%), diarrhea (2% to 5%), dyspepsia (1% to 3%), nausea (3% to 4%), vomiting (1% to 5%)
Genitourinary: Vulvovaginal candidiasis (2%)
Local: Injection-site reaction (IV: >1%)
Nervous system: Dizziness (IV: <1%; oral: 2%), drowsiness, headache (IV: >1%; oral: 1% to 3%), insomnia, nervousness, neurological signs and symptoms (IV: children: 3%), restlessness (IV: >1%; oral: <1%)
Respiratory: Asthma (children: 2%)
Miscellaneous: Fever (children: 2%; adults: <1%)
<1%:
Cardiovascular: Acute myocardial infarction, angina pectoris, flushing, hypertension, hypotension, syncope, tachycardia, thrombophlebitis, vasculitis, vasodilation
Dermatologic: Diaphoresis, erythema multiforme, erythema nodosum, exfoliative dermatitis, phototoxicity, pruritus, skin photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria
Endocrine & metabolic: Albuminuria, gynecomastia, hyperglycemia, hypoglycemia
Gastrointestinal: Abdominal distress, anorexia, Clostridioides difficile colitis, constipation, dysgeusia, flatulence, gastrointestinal hemorrhage, intestinal obstruction, intestinal perforation, oral mucosa ulcer, pancreatitis, xerostomia
Genitourinary: Crystalluria, hematuria, hemorrhagic cystitis, urinary frequency
Hematologic & oncologic: Agranulocytosis, petechia, prolonged prothrombin time, purpuric disease
Hepatic: Cholestatic jaundice, hepatic necrosis, hepatitis
Hypersensitivity: Anaphylactic shock, anaphylaxis, angioedema
Nervous system: Abnormal gait, anosmia, asthenia, ataxia, burning sensation, confusion, depersonalization, depression, hallucination, hypertonia, irritability, malaise, manic reaction, migraine, myasthenia, nightmares, pain, paranoid ideation, paresthesia, phobia, seizure, status epilepticus, suicidal ideation, suicidal tendencies, toxic psychosis, tremor, unresponsive to stimuli
Neuromuscular & skeletal: Arthralgia, joint stiffness
Ophthalmic: Blurred vision, chromatopsia, decreased visual acuity, diplopia, nystagmus disorder, photopsia
Otic: Hearing loss, tinnitus
Renal: Acute kidney injury, casts in urine, interstitial nephritis, nephrolithiasis
Respiratory: Bronchospasm, dyspnea, hemoptysis, laryngeal edema
Postmarketing:
Cardiovascular: Aortic aneurysm (Ref), aortic dissection (Ref), bradycardia (Ref), prolonged QT interval on ECG (Ref), torsades de pointes (Ref)
Dermatologic: Acute generalized exanthematous pustulosis (Ref), fixed drug eruption (Ref), maculopapular rash (Ref)
Endocrine & metabolic: SIADH (Ref)
Gastrointestinal: Ageusia, Clostridioides difficile-associated diarrhea (Ref)
Hematologic & oncologic: Anemia (Ref), eosinophilia (Ref), hemolytic anemia (Ref), leukopenia (Ref), lymphocytosis (Ref), methemoglobinemia, monocytosis (Ref), pancytopenia (Ref), thrombocytopenia (Ref), thrombocytosis
Hepatic: Cholestatic hepatitis (Ref), hepatic failure, hepatotoxicity (Ref)
Hypersensitivity: Drug reaction with eosinophilia and systemic symptoms (Ref), hypersensitivity angiitis (Ref), nonimmune anaphylaxis (Ref), serum sickness-like reaction (Ref)
Infection: Candidiasis
Nervous system: Agitation, anxiety, delirium (Ref), disturbance in attention, encephalopathy (Ref), exacerbation of myasthenia gravis (Ref), Guillain-Barré syndrome (Ref), hyperesthesia, hypoesthesia, increased intracranial pressure, intracranial hypertension (Ref), memory impairment, myoclonus (Ref), peripheral neuropathy (may be irreversible) (Ref), polyneuropathy, posterior reversible encephalopathy syndrome (Ref), twitching
Neuromuscular & skeletal: Exacerbation of systemic lupus erythematous (Ref), myalgia, rupture of tendon (Ref), tendinopathy (Ref)
Ophthalmic: Retinal detachment (inconsistent data) (Ref)
Respiratory: Pneumonitis (including interstitial pneumonitis) (Ref)
Hypersensitivity to ciprofloxacin, any component of the formulation, or other quinolones; concurrent administration of tizanidine
Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Canadian labeling: Additional contraindications (not in the US labeling): Concurrent administration of agomelatine
Concerns related to adverse effects:
• Crystalluria: Rarely, crystalluria has occurred; urine alkalinity may increase the risk. Ensure adequate hydration during therapy.
• Superinfection: Prolonged use may result in fungal or bacterial superinfection.
Disease-related concerns:
• Renal impairment: Use with caution in patients with renal impairment; dosage adjustment required.
• Syphilis: Since ciprofloxacin is ineffective in the treatment of syphilis and may mask symptoms, all patients should be tested for syphilis at the time of gonorrheal diagnosis and 3 months later.
Special populations:
• Older adult: Adverse effects (eg, tendon rupture, QT changes) may be increased in elderly patients.
• G6PD deficiency: Hemolytic reactions may (rarely) occur with fluoroquinolone use in patients with G6PD deficiency (Luzzatto 2020).
• Pediatric: Adverse effects, including those related to joints and/or surrounding tissues, are increased in pediatric patients and therefore, ciprofloxacin should not be considered as drug of choice in children (exception is anthrax treatment).
ER tablets [Canadian product] and IR formulations are not interchangeable.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Intravenous:
Generic: 200 mg/100 mL (100 mL); 400 mg/200 mL (200 mL)
Solution, Intravenous [preservative free]:
Generic: 200 mg/100 mL (100 mL); 400 mg/200 mL (200 mL)
Suspension Reconstituted, Oral:
Cipro: 250 mg/5 mL (100 mL); 500 mg/5 mL (100 mL) [strawberry flavor]
Generic: 250 mg/5 mL (100 mL [DSC]); 500 mg/5 mL (100 mL [DSC])
Tablet, Oral, as hydrochloride [strength expressed as base]:
Cipro: 250 mg, 500 mg
Generic: 100 mg [DSC], 250 mg, 500 mg, 750 mg
Yes
Solution (Ciprofloxacin in D5W Intravenous)
200 mg/100 mL (per mL): $0.04
400 mg/200 mL (per mL): $0.02 - $0.04
Suspension (reconstituted) (Cipro Oral)
250 MG/5ML (5%) (per mL): $1.56
500 MG/5ML (10%) (per mL): $1.83
Tablets (Cipro Oral)
250 mg (per each): $5.88
500 mg (per each): $6.88
Tablets (Ciprofloxacin HCl Oral)
250 mg (per each): $2.24 - $4.59
500 mg (per each): $0.37 - $5.59
750 mg (per each): $5.45 - $6.19
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Intravenous:
Generic: 2 mg/mL in D5W (100 mL, 200 mL)
Suspension Reconstituted, Oral:
Cipro: 500 mg/5 mL (100 mL) [contains soybean lecithin]
Tablet, Oral, as hydrochloride [strength expressed as base]:
Generic: 100 mg, 250 mg, 500 mg, 750 mg
Tablet Extended Release 24 Hour, Oral, as base and hydrochloride [strength expressed as base]:
Cipro XL: 500 mg [DSC], 1000 mg [DSC]
Generic: 500 mg
IV: Administer by slow IV infusion over 60 minutes into a large vein (reduces risk of venous irritation).
Oral: May administer with most foods to minimize GI upset; avoid antacid use; maintain proper hydration and urine output. Avoid concomitant administration with dairy products (eg, milk, yogurt) or calcium-fortified products alone; however, may be taken with meals that contain these products; separate administration of extended-release tablets [Canadian product] and calcium >800 mg by at least 2 hours. Administer all oral ciprofloxacin formulations at least 2 hours before or 6 hours after antacids or other products containing calcium, iron, or zinc. Separate oral administration from drugs that may impair absorption (see "Drug Interactions").
Oral suspension: Shake vigorously before use for ~15 seconds; administer using the co-packaged graduated teaspoon. Do not chew the microcapsules in the suspension; swallow whole.
Tablet, extended release [Canadian product]: Do not crush, split, or chew.
Bariatric surgery: Some institutions may have specific protocols that conflict with these recommendations; refer to institutional protocols as appropriate. Switch to IR formulation (tablet or oral solution).
Enteral feeding tube:
The following recommendations are based upon the best available evidence and clinical expertise. Senior editorial team: Joseph I. Boullata, PharmD, RPh, CNS-S, FASPEN, FACN; Peggi A. Guenter PhD, RN, FASPEN; Kathleen Gura, PharmD, BCNSP, FASHP, FASPEN, FPPA, FMSHP; Mark G. Klang MS, RPh, BCNSP, PhD, FASPEN; Linda Lord, NP, ACNP-BC, CNSC, FASPEN.
Oral suspension (commercially available):
Enteral feeding tube administration utilizing ciprofloxacin oral suspension is not recommended due to the physical characteristics of the suspension (Ref).
Oral tablet, extended release [Canadian product]:
Enteral feeding tube administration utilizing ciprofloxacin ER tablets is not recommended. Crushing modified-release dosage forms (eg, ER tablets) may result in release of excessive doses, variable serum concentrations, and risk of severe adverse effects (Ref).
Oral tablet, immediate release:
Gastric (eg, NG, G-tube) or post-pyloric (eg, J-tube) tubes (≥8 French): Consider separating ciprofloxacin administration from enteral nutrition (EN) based on patient-specific factors and institutional policy. Crush tablet(s) into a fine powder and disperse in 10 to 50 mL purified water; draw up mixture into enteral dosing syringe and administer via feeding tube (Ref). Monitor patient closely if administered post-pylorically; absorption may be reduced (Ref).
Dosage form information: Some formulations may be film-coated; administration of film-coated ciprofloxacin tablets via feeding tube may increase the risk of clogging the tube; if used, ensure tablets are dispersed sufficiently with an adequate amount of purified water prior to administration (Ref).
General guidance: May consider holding EN for 1 to 2 hours before and 1 to 2 hours following ciprofloxacin tablet administration, based on patient-specific factors and institutional policy, for adequate absorption (Ref). Flush feeding tube with an appropriate volume of purified water (eg, 15 mL) before administration (Ref). Following administration, rinse container used for preparation with purified water; draw up rinse and administer contents to ensure delivery of entire dose (Ref). Flush feeding tube with an appropriate volume of purified water (eg, 60 mL) and restart EN (Ref); consider restarting EN 2 hours after ciprofloxacin administration to ensure adequate absorption. The interruption of enteral feeding to allow for ciprofloxacin administration may impact patient nutrition; adjustment of feeding rates may be necessary to meet patient’s nutritional needs (Ref). Note : Manufacturer’s labeling suggests ciprofloxacin tablets can be administered without regard to meals. However, reduced serum concentrations have been reported with crushed ciprofloxacin tablets when administered with EN (Ref); other studies suggest holding feeds may not be necessary (Ref).
Enteral nutrition considerations: Fluoroquinolone absorption study results have been mixed when administered with EN; while studies in healthy volunteers suggest separation of EN and fluoroquinolones is not necessary, other studies suggest absorption can be variable, particularly in certain patient populations (eg, critically ill). Patient-specific parameters (eg, illness severity, post abdominal surgery, composition of feeds) and institutional policies should be considered when determining how to time administration (Ref).
No te: Recommendations may not account for differences in inactive ingredients, osmolality, or other formulation properties that may vary among products from different manufacturers.
The following feeding tube recommendations are based upon the best available evidence and clinical expertise. Senior editor panel: Joseph I. Boullata, PharmD, RPh, CNS-S, FASPEN, FACN; Peggi A. Guenter, PhD, RN, FASPEN; Kathleen Gura, PharmD, BCNSP, FASHP, FASPEN, FPPA, FMSHP; Mark G. Klang, MS, RPh, BCNSP, PhD, FASPEN; Linda Lord, NP, ACNP-BC, CNSC, FASPEN.
Note: Recommendations may not account for differences in inactive ingredients, osmolality, or other formulation properties that may vary among products from different manufacturers.
Oral: May administer with food to minimize GI upset. Maintain adequate hydration and urine output.
Oral suspension (commercially available): Shake vigorously for ~15 seconds prior to each dose. Do not chew the microcapsules in the suspension; swallow whole. Administer with an accurate measuring device; do not use a household teaspoon (overdosage may occur).
Administration via feeding tube: NOT recommended: Enteral feeding tube administration utilizing ciprofloxacin oral suspension is not recommended due to the physical characteristics of the suspension. The suspension is thick, which increases risk of clogging, and is oil-based so is not easily flushed (Ref).
Tablet, immediate release:
Administration via feeding tube:
Gastric (eg, NG, G-tube) or post-pyloric (eg, J-tube) tubes (≥8 French): Consider separating ciprofloxacin administration from enteral nutrition based on patient-specific factors and institutional policy. Crush tablet(s) into a fine powder and disperse in 5 to 20 mL purified water; draw up mixture into enteral dosing syringe and administer via feeding tube (Ref). Monitor patient closely if administered post-pylorically, as absorption may be reduced (Ref).
Dosage form information: Some tablets may be film-coated; administration of film-coated ciprofloxacin tablets via feeding tube may increase the risk of clogging the tube; if used, ensure tablets are sufficiently dispersed prior to administration (Ref).
General guidance: May consider holding enteral nutrition for 1 to 2 hours before and 1 to 2 hours following ciprofloxacin tablet administration, based on patient-specific factors and institutional policy, for adequate absorption (Ref). Flush feeding tube with the lowest volume of purified water necessary to clear the tube prior to administration based on size of patient and/or feeding tube (eg, neonates: 1 to 3 mL; infants and children: 2 to 5 mL; adolescents: 15 mL); refer to institutional policies and procedures (Ref). Following administration, rinse container used for preparation with purified water; draw up rinse and administer contents to ensure delivery of entire dose (Ref). Flush feeding tube with an appropriate volume of purified water and restart enteral nutrition; consider restarting enteral nutrition 1 to 2 hours after ciprofloxacin administration to ensure adequate absorption (Ref). The interruption of enteral feeding to allow for ciprofloxacin administration may impact patient nutrition; adjustment of feeding rates may be necessary to meet patient's nutritional needs (Ref). Note: Manufacturer's labeling suggests ciprofloxacin tablets can be administered without regard to meals. However, reduced serum concentrations have been reported with crushed ciprofloxacin tablets when administered with enteral nutrition (Ref); other studies suggest holding feeds may not be necessary (Ref).
Note: Enteral nutrition considerations: Studies evaluating fluoroquinolone absorption when administered with enteral nutrition have mixed results; while studies in healthy volunteers suggest separation of enteral nutrition and fluoroquinolones is not necessary, other studies suggest absorption can be variable, particularly in certain patient populations (eg, critically ill). Patient-specific parameters (eg, illness severity, post abdominal surgery, composition of feeds) and institutional policies should be considered when determining how to time administration (Ref).
Missed dose: Immediate release (oral suspension, tablet): Administer as soon as possible if ≥6 hours until next scheduled dose; otherwise, wait until next scheduled dose.
Parenteral: Administer by slow IV infusion over 60 minutes to reduce the risk of venous irritation (burning, pain, erythema, and swelling).
An FDA-approved patient medication guide, which is available with the product information and as follows, must be dispensed with this medication:
Cipro: https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/019537s095,020780s050lbl.pdf#page=40
Children and Adolescents: Treatment of complicated urinary tract infections and pyelonephritis due to E. coli. Note: Although effective, ciprofloxacin is not the drug of first choice in children.
Infants, Children, Adolescents, and Adults: Prophylaxis to reduce incidence or progression of disease following inhalation exposure to Bacillus anthracis; prophylaxis and treatment of plague (Yersinia pestis).
Adults: Treatment of the following infections when caused by susceptible bacteria: Urinary tract infection; acute uncomplicated cystitis in females, chronic bacterial prostatitis, acute bacterial exacerbations of chronic bronchitis, acute bacterial rhinosinusitis, skin and soft tissue infections, bone and joint infections, complicated intra-abdominal infections (in combination with metronidazole), infectious diarrhea, typhoid fever (Salmonella typhi), hospital-acquired (nosocomial) pneumonia, uncomplicated cervical and urethral gonorrhea.
Limitations of use: Because fluoroquinolones have been associated with disabling and potentially irreversible serious adverse reactions (eg, tendinopathy and tendon rupture, peripheral neuropathy, CNS effects), reserve ciprofloxacin for use in patients who have no alternative treatment options for acute uncomplicated cystitis, acute bacterial rhinosinusitis, and for acute exacerbations of chronic bronchitis when treatment is necessary.
Anthrax, treatment; Bite wound infection (animal and human bites); Bronchiectasis, acute exacerbation; Cat scratch disease, lymphadenitis (nondisseminated); Chancroid; Cholera (Vibrio cholerae); Chronic obstructive pulmonary disease, acute exacerbation; Crohn disease, treatment of simple perianal fistulas; Diabetic foot infection; Endocarditis, treatment; Meningitis, bacterial; Meningococcal meningitis prophylaxis; Neutropenia (chemotherapy-induced), antibacterial prophylaxis; Neutropenic fever, low-risk cancer patients (empiric therapy); Pouchitis (post–ileal pouch-anal anastomosis), acute; Prosthetic joint infection; Spontaneous bacterial peritonitis, prophylaxis; Surgical prophylaxis; Tularemia
Ciprofloxacin may be confused with cephalexin
Cipro may be confused with Ceftin
Substrate of OAT1/3, P-glycoprotein (Minor); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential; Inhibits CYP1A2 (Moderate), CYP3A4 (Weak);
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Agents with Blood Glucose Lowering Effects: Quinolones may increase hypoglycemic effects of Agents with Blood Glucose Lowering Effects. Quinolones may decrease therapeutic effects of Agents with Blood Glucose Lowering Effects. Specifically, if an agent is being used to treat diabetes, loss of blood sugar control may occur with quinolone use. Risk C: Monitor
Agomelatine: Ciprofloxacin (Systemic) may increase serum concentration of Agomelatine. Risk X: Avoid
Alosetron: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Alosetron. Management: Avoid concomitant use of alosetron and moderate CYP1A2 inhibitors whenever possible. If combined use is necessary, monitor for increased alosetron effects/toxicities. Risk D: Consider Therapy Modification
ALPRAZolam: CYP3A4 Inhibitors (Weak) may increase serum concentration of ALPRAZolam. Risk C: Monitor
Aminolevulinic Acid (Systemic): Photosensitizing Agents may increase photosensitizing effects of Aminolevulinic Acid (Systemic). Risk X: Avoid
Aminolevulinic Acid (Topical): Photosensitizing Agents may increase photosensitizing effects of Aminolevulinic Acid (Topical). Risk C: Monitor
Amphetamines: May increase cardiotoxic effects of Quinolones. Risk C: Monitor
Anagrelide: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Anagrelide. CYP1A2 Inhibitors (Moderate) may increase active metabolite exposure of Anagrelide. Risk C: Monitor
Antacids: May decrease absorption of Quinolones. Of concern only with oral administration of quinolones. Management: Avoid concurrent administration of quinolones and antacids to minimize the impact of this interaction. Recommendations for optimal dose separation vary by specific quinolone; see full monograph for details. Risk D: Consider Therapy Modification
Asenapine: Ciprofloxacin (Systemic) may increase serum concentration of Asenapine. Risk C: Monitor
Ataluren: May increase serum concentration of Ciprofloxacin (Systemic). Risk C: Monitor
Bacillus clausii: Antibiotics may decrease therapeutic effects of Bacillus clausii. Management: Bacillus clausii should be taken in between antibiotic doses during concomitant therapy. Risk D: Consider Therapy Modification
BCG (Intravesical): Antibiotics may decrease therapeutic effects of BCG (Intravesical). Risk X: Avoid
BCG Vaccine (Immunization): Antibiotics may decrease therapeutic effects of BCG Vaccine (Immunization). Risk C: Monitor
Bendamustine: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Bendamustine. Management: Consider alternatives to moderate CYP1A2 inhibitors during therapy with bendamustine due to the potential for increased bendamustine plasma concentrations and increased bendamustine toxicity. Risk D: Consider Therapy Modification
Caffeine and Caffeine Containing Products: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Caffeine and Caffeine Containing Products. Risk C: Monitor
Calcium Salts: May decrease absorption of Quinolones. Of concern only with oral administration of both agents. Management: Consider administering an oral quinolone at least 2 hours before or 6 hours after the dose of oral calcium to minimize this interaction. Monitor for decreased therapeutic effects of quinolones during coadministration. Risk D: Consider Therapy Modification
CarBAMazepine: CYP3A4 Inhibitors (Weak) may increase serum concentration of CarBAMazepine. Risk C: Monitor
Chloroquine: May increase hyperglycemic effects of Ciprofloxacin (Systemic). Chloroquine may increase hypoglycemic effects of Ciprofloxacin (Systemic). Chloroquine may increase QTc-prolonging effects of Ciprofloxacin (Systemic). Risk C: Monitor
Cholera Vaccine: Antibiotics may decrease therapeutic effects of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Risk X: Avoid
ClomiPRAMINE: CYP1A2 Inhibitors (Moderate) may increase serum concentration of ClomiPRAMINE. Risk C: Monitor
CloZAPine: Ciprofloxacin (Systemic) may increase QTc-prolonging effects of CloZAPine. Ciprofloxacin (Systemic) may increase serum concentration of CloZAPine. Management: Reduce the clozapine dose to one-third of the original dose when adding ciprofloxacin and monitor closely for evidence of excessive QTc prolongation and clozapine toxicity. Resume the previous clozapine dose following ciprofloxacin discontinuation. Risk D: Consider Therapy Modification
Corticosteroids (Systemic): May increase adverse/toxic effects of Quinolones. Specifically, the risk of tendonitis and tendon rupture may be increased. Risk C: Monitor
CycloSPORINE (Systemic): Ciprofloxacin (Systemic) may increase nephrotoxic effects of CycloSPORINE (Systemic). Risk C: Monitor
Delamanid: Quinolones may increase QTc-prolonging effects of Delamanid. Management: Avoid concomitant use if possible. If coadministration is unavoidable, frequent monitoring of electrocardiograms (ECGs) throughout the full delamanid treatment period should occur. Risk D: Consider Therapy Modification
Diazoxide Choline: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Diazoxide Choline. Risk C: Monitor
Didanosine: Quinolones may decrease serum concentration of Didanosine. Didanosine may decrease serum concentration of Quinolones. Management: Administer oral quinolones at least 2 hours before or 6 hours after didanosine. Monitor for decreased therapeutic effects of quinolones, particularly if doses cannot be separated as recommended. This does not apply to unbuffered enteric coated didanosine. Risk D: Consider Therapy Modification
Dofetilide: CYP3A4 Inhibitors (Weak) may increase serum concentration of Dofetilide. Risk C: Monitor
DULoxetine: CYP1A2 Inhibitors (Moderate) may increase serum concentration of DULoxetine. Risk C: Monitor
Erlotinib: Ciprofloxacin (Systemic) may increase serum concentration of Erlotinib. Management: Avoid use of this combination when possible. When the combination must be used, monitor the patient closely for the development of severe adverse reactions, and if such severe reactions occur, reduce the erlotinib dose (in 50 mg decrements). Risk D: Consider Therapy Modification
Fecal Microbiota (Live) (Oral): May decrease therapeutic effects of Antibiotics. Risk X: Avoid
Fecal Microbiota (Live) (Rectal): Antibiotics may decrease therapeutic effects of Fecal Microbiota (Live) (Rectal). Risk X: Avoid
Fexinidazole: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Management: Avoid use of fexinidazole with OAT1/3 substrates when possible. If combined, monitor for increased OAT1/3 substrate toxicities. Risk D: Consider Therapy Modification
Fezolinetant: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Fezolinetant. Risk X: Avoid
Finerenone: CYP3A4 Inhibitors (Weak) may increase serum concentration of Finerenone. Risk C: Monitor
Flibanserin: CYP3A4 Inhibitors (Weak) may increase serum concentration of Flibanserin. Risk C: Monitor
Fosphenytoin: Ciprofloxacin (Systemic) may decrease therapeutic effects of Fosphenytoin. Ciprofloxacin (Systemic) may decrease serum concentration of Fosphenytoin. Risk C: Monitor
Haloperidol: QT-prolonging Agents (Indeterminate Risk - Avoid) may increase QTc-prolonging effects of Haloperidol. Risk C: Monitor
Hydroxychloroquine: May increase hyperglycemic effects of Ciprofloxacin (Systemic). Hydroxychloroquine may increase hypoglycemic effects of Ciprofloxacin (Systemic). Hydroxychloroquine may increase QTc-prolonging effects of Ciprofloxacin (Systemic). Risk C: Monitor
Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies): Antibiotics may decrease therapeutic effects of Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies). Risk C: Monitor
Iron Preparations: May decrease serum concentration of Quinolones. Management: Give oral quinolones at least several hours before (4 h for moxi- and sparfloxacin, 2 h for others) or after (8 h for moxi-, 6 h for cipro/dela-, 4 h for lome-, 3 h for gemi-, and 2 h for enox-, levo-, nor-, oflox-, peflox, or nalidixic acid) oral iron. Risk D: Consider Therapy Modification
Ixabepilone: CYP3A4 Inhibitors (Weak) may increase serum concentration of Ixabepilone. Risk C: Monitor
Lactobacillus and Estriol: Antibiotics may decrease therapeutic effects of Lactobacillus and Estriol. Risk C: Monitor
Lanthanum: May decrease serum concentration of Quinolones. Management: Administer oral quinolone antibiotics at least one hour before or four hours after lanthanum. Risk D: Consider Therapy Modification
Leflunomide: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor
Lemborexant: CYP3A4 Inhibitors (Weak) may increase serum concentration of Lemborexant. Management: The maximum recommended dosage of lemborexant is 5 mg, no more than once per night, when coadministered with weak CYP3A4 inhibitors. Risk D: Consider Therapy Modification
Levoketoconazole: QT-prolonging Agents (Indeterminate Risk - Avoid) may increase QTc-prolonging effects of Levoketoconazole. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Levomethadone: Ciprofloxacin (Systemic) may increase serum concentration of Levomethadone. Risk C: Monitor
Lomitapide: Ciprofloxacin (Systemic) may increase serum concentration of Lomitapide. Risk X: Avoid
Lumateperone: Ciprofloxacin (Systemic) may increase serum concentration of Lumateperone. Risk C: Monitor
Magnesium Salts: May decrease serum concentration of Quinolones. Management: Administer oral quinolones several hours before (4 h for moxi/pe/spar/enox-, 2 h for others) or after (8 h for moxi-, 6 h for cipro/dela-, 4 h for lome/pe/enox-, 3 h for gemi-, and 2 h for levo-, nor-, or ofloxacin or nalidixic acid) oral magnesium salts. Risk D: Consider Therapy Modification
Melatonin: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Melatonin. Risk C: Monitor
Meptazinol: May decrease serum concentration of Ciprofloxacin (Systemic). Risk X: Avoid
Methotrexate: Ciprofloxacin (Systemic) may increase serum concentration of Methotrexate. Risk C: Monitor
Methoxsalen (Systemic): Photosensitizing Agents may increase photosensitizing effects of Methoxsalen (Systemic). Risk C: Monitor
Methylphenidate: May increase cardiotoxic effects of Quinolones. Risk C: Monitor
Midazolam: CYP3A4 Inhibitors (Weak) may increase serum concentration of Midazolam. Risk C: Monitor
Multivitamins/Minerals (with ADEK, Folate, Iron): May decrease serum concentration of Quinolones. Specifically, polyvalent cations in multivitamin products may decrease the absorption of orally administered quinolone antibiotics. Management: Administer oral quinolones at least 2 hours before, or 6 hours after, the dose of a multivitamin that contains polyvalent cations (ie, calcium, iron, magnesium, selenium, zinc). Monitor for decreased quinolone efficacy. Risk D: Consider Therapy Modification
Multivitamins/Minerals (with AE, No Iron): May decrease serum concentration of Quinolones. Specifically, minerals in the multivitamin/mineral product may impair absorption of quinolone antibiotics. Management: Administer oral quinolones at least 2 hours before, or 6 hours after, the dose of a multivitamin that contains polyvalent cations (ie, calcium, iron, magnesium, selenium, zinc). Monitor for decreased therapeutic effects of quinolones. Risk D: Consider Therapy Modification
Mycophenolate: Antibiotics may decrease active metabolite exposure of Mycophenolate. Specifically, concentrations of mycophenolic acid (MPA) may be reduced. Risk C: Monitor
Nadifloxacin: May increase adverse/toxic effects of Quinolones. Risk X: Avoid
NiMODipine: CYP3A4 Inhibitors (Weak) may increase serum concentration of NiMODipine. Risk C: Monitor
Nitisinone: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor
Nonsteroidal Anti-Inflammatory Agents: May increase neuroexcitatory and/or seizure-potentiating effects of Quinolones. Nonsteroidal Anti-Inflammatory Agents may increase serum concentration of Quinolones. Risk C: Monitor
OLANZapine: CYP1A2 Inhibitors (Moderate) may increase serum concentration of OLANZapine. Risk C: Monitor
Patiromer: May decrease serum concentration of Ciprofloxacin (Systemic). Management: Administer oral ciprofloxacin at least 3 hours before or 3 hours after patiromer. Risk D: Consider Therapy Modification
Pentoxifylline: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Pentoxifylline. Risk C: Monitor
Phenytoin: Ciprofloxacin (Systemic) may decrease therapeutic effects of Phenytoin. Ciprofloxacin (Systemic) may decrease serum concentration of Phenytoin. Risk C: Monitor
Pimozide: CYP3A4 Inhibitors (Weak) may increase serum concentration of Pimozide. Risk X: Avoid
Pirfenidone: Ciprofloxacin (Systemic) may increase serum concentration of Pirfenidone. Management: Avoid this combination if possible. With ciprofloxacin doses of 1,500 mg/day, the pirfenidone dose should be reduced to 1,602 mg per (534 mg three times a day). With lower daily doses of ciprofloxacin, use pirfenidone with caution. Risk D: Consider Therapy Modification
Polyethylene Glycol-Electrolyte Solution: May decrease absorption of Quinolones. Management: Give oral quinolones at least 2 hours before or at least 6 hours after polyethylene glycol-electrolyte solutions that contain magnesium sulfate (Suflave brand). Other products without magnesium do not require dose separation. Risk D: Consider Therapy Modification
Pomalidomide: Ciprofloxacin (Systemic) may increase serum concentration of Pomalidomide. Management: Avoid concomitant use of pomalidomide and ciprofloxacin when possible. If coadministration is considered necessary, consider reducing the pomalidomide dose to 2 mg and monitoring patients for increased pomalidomide effects/toxicities. Risk D: Consider Therapy Modification
Porfimer: Photosensitizing Agents may increase photosensitizing effects of Porfimer. Risk X: Avoid
Pretomanid: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor
Probenecid: May increase serum concentration of Quinolones. Probenecid may decrease excretion of Quinolones. Specifically, probenecid may decreased the renal excretion of quinolone antibiotics. Risk C: Monitor
Propranolol: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Propranolol. Risk C: Monitor
QT-prolonging Agents (Highest Risk): QT-prolonging Agents (Indeterminate Risk - Avoid) may increase QTc-prolonging effects of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Ramelteon: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Ramelteon. Risk C: Monitor
Ramosetron: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Ramosetron. Risk C: Monitor
Rasagiline: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Rasagiline. Management: Limit rasagiline dose to 0.5 mg once daily in patients taking moderate CYP1A2 inhibitors. Risk D: Consider Therapy Modification
Roflumilast-Containing Products: Ciprofloxacin (Systemic) may increase serum concentration of Roflumilast-Containing Products. Risk C: Monitor
ROPINIRole: CYP1A2 Inhibitors (Moderate) may increase serum concentration of ROPINIRole. Risk C: Monitor
ROPivacaine: CYP1A2 Inhibitors (Moderate) may increase serum concentration of ROPivacaine. Risk C: Monitor
Sevelamer: May decrease serum concentration of Ciprofloxacin (Systemic). Management: Administer ciprofloxacin at least 2 hours before or 6 hours after sevelamer administration. Risk D: Consider Therapy Modification
Sildenafil: Ciprofloxacin (Systemic) may increase serum concentration of Sildenafil. Risk C: Monitor
Simvastatin: Ciprofloxacin (Systemic) may increase myopathic (rhabdomyolysis) effects of Simvastatin. Ciprofloxacin (Systemic) may increase serum concentration of Simvastatin. Risk C: Monitor
Sirolimus (Conventional): CYP3A4 Inhibitors (Weak) may increase serum concentration of Sirolimus (Conventional). Risk C: Monitor
Sirolimus (Protein Bound): CYP3A4 Inhibitors (Weak) may increase serum concentration of Sirolimus (Protein Bound). Management: Reduce the dose of protein bound sirolimus to 56 mg/m2 when used concomitantly with a weak CYP3A4 inhibitor. Risk D: Consider Therapy Modification
Sodium Picosulfate: Antibiotics may decrease therapeutic effects of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Risk D: Consider Therapy Modification
Spironolactone: May increase arrhythmogenic effects of Ciprofloxacin (Systemic). Risk C: Monitor
Strontium Ranelate: May decrease serum concentration of Quinolones. Management: In order to minimize any potential impact of strontium ranelate on quinolone antibiotic concentrations, it is recommended that strontium ranelate treatment be interrupted during quinolone therapy. Risk X: Avoid
Sucralfate: May decrease serum concentration of Quinolones. Management: Avoid concurrent administration of quinolones and sucralfate to minimize the impact of this interaction. Recommendations for optimal dose separation vary by specific quinolone. Risk D: Consider Therapy Modification
Tacrolimus (Systemic): CYP3A4 Inhibitors (Weak) may increase serum concentration of Tacrolimus (Systemic). Risk C: Monitor
Tasimelteon: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Tasimelteon. Risk C: Monitor
Taurursodiol: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk X: Avoid
Teriflunomide: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor
Theophylline Derivatives: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Theophylline Derivatives. Management: Consider avoidance of this combination. If coadministration is necessary, monitor for increased theophylline serum concentrations and toxicities when combined. Theophylline dose reductions will likely be required. Risk D: Consider Therapy Modification
Thyroid Products: Ciprofloxacin (Systemic) may decrease serum concentration of Thyroid Products. Risk C: Monitor
TiZANidine: Ciprofloxacin (Systemic) may increase serum concentration of TiZANidine. Risk X: Avoid
Triazolam: CYP3A4 Inhibitors (Weak) may increase serum concentration of Triazolam. Risk C: Monitor
Typhoid Vaccine: Antibiotics may decrease therapeutic effects of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Avoid use of live attenuated typhoid vaccine (Ty21a) in patients being treated with systemic antibacterial agents. Postpone vaccination until 3 days after cessation of antibiotics and avoid starting antibiotics within 3 days of last vaccine dose. Risk D: Consider Therapy Modification
Ubrogepant: Ciprofloxacin (Systemic) may increase serum concentration of Ubrogepant. Management: Use an initial ubrogepant dose of 50 mg and consider avoiding a second dose for 24 hours when used with ciprofloxacin. Risk D: Consider Therapy Modification
Vaborbactam: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor
Vadadustat: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor
Verteporfin: Photosensitizing Agents may increase photosensitizing effects of Verteporfin. Risk C: Monitor
Vitamin K Antagonists: Quinolones may increase anticoagulant effects of Vitamin K Antagonists. Risk C: Monitor
Vorasidenib: CYP1A2 Inhibitors (Moderate) may increase serum concentration of Vorasidenib. Management: Avoid concurrent use with moderate CYP1A2 inhibitors when possible. If combined use cannot be avoided, monitor for evidence of adverse effects and adjust vorasidenib dose accordingly if necessary. Risk D: Consider Therapy Modification
Zinc Salts: May decrease serum concentration of Quinolones. Management: Give oral quinolones at several hours before (4 h for moxi- and sparfloxacin, 2 h for others) or after (8 h for moxi-, 6 h for cipro/dela-, 4 h for lome-, 3 h for gemi-, and 2 h for enox-, levo-, nor-, pe- or ofloxacin or nalidixic acid) oral zinc salts. Risk D: Consider Therapy Modification
Zolpidem: Ciprofloxacin (Systemic) may increase serum concentration of Zolpidem. Management: Consider avoiding the combination of ciprofloxacin and zolpidem if possible. If combined, monitor for signs of zolpidem toxicity (eg, somnolence, dizziness, lethargy). Risk D: Consider Therapy Modification
Food decreases rate, but not extent, of absorption. Ciprofloxacin may increase serum caffeine levels if taken concurrently. Rarely, crystalluria may occur. Management: May administer with most foods to minimize GI upset. If unable to avoid concomitant administration with dairy products or calcium-fortified products alone, administer ciprofloxacin at least 2 hours before or 6 hours after these foods/products; however, may be taken with meals that contain these products. Separate administration of extended-release tablets [Canadian product] and calcium >800 mg by at least 2 hours. Restrict caffeine intake if excessive cardiac or CNS stimulation occurs. Ensure adequate hydration during therapy.
Ciprofloxacin crosses the placenta and produces measurable concentrations in the amniotic fluid and cord serum (Ludlam 1997).
Based on available data, an increased risk of major birth defects, miscarriage, or other adverse fetal and maternal outcomes have not been observed following ciprofloxacin use during pregnancy.
Due to pregnancy-induced physiologic changes, some pharmacokinetic properties of ciprofloxacin may be altered. Serum concentrations of ciprofloxacin may be lower during pregnancy than in nonpregnant patients (Giamarellou 1989).
Recommendations for using ciprofloxacin in the management of B. anthracis during pregnancy are available. Maternal infection with B. anthracis may cause preterm labor, fetal infection, fetal distress, or fetal loss. Maternal death may also occur. Ciprofloxacin is a first line option for the treatment of cutaneous anthrax without CNS involvement, systemic anthrax (with or without CNS involvement), and for the postexposure prophylaxis of B. anthracis during pregnancy. The dose of ciprofloxacin in pregnant and postpartum patients is the same as in nonpregnant adults, although duration of therapy for postexposure prophylaxis is not dependent on vaccination status (CDC [Bower 2023]; Meaney-Delman 2014).
Untreated plague (Yersinia pestis) infections in pregnant patients may result in hemorrhage (including postpartum hemorrhage), maternal and fetal death, preterm birth, and stillbirth. Limited data suggest maternal-fetal transmission of Y. pestis can occur if not treated. Pregnant patients should be treated for Y. pestis; parenteral antibiotics are preferred for initial treatment when otherwise appropriate. Ciprofloxacin is one of the fluroquinolones recommended for use (in combination with an aminoglycoside) for treating pregnant patients with bubonic, pharyngeal, pneumonic, or septicemic plague. Ciprofloxacin may also be used for pre- and postexposure prophylaxis in pregnant patients exposed to Y. pestis. Dose adjustments may be required (CDC [Nelson 2021]).
Alternative antibiotics are recommended in pregnant patients for indications such as chancroid (CDC [Workowski 2021]), meningococcal disease (CDC [Cohn 2013]), or perianal disease and pouchitis in pregnant patients with inflammatory bowel disease (AGA [Mahadevan 2019]).
Ciprofloxacin is present in breast milk.
Information related to the presence of ciprofloxacin in breast milk is available from 10 lactating women given oral ciprofloxacin 750 mg every 12 hours for 3 doses. Average milk concentrations were highest 2 hours after the dose (3.79 mcg/mL) and decreased to 0.02 mcg/mL 24 hours after the last dose (Giamarellou 1989). Using the milk concentration of 3.79 mcg/mL, another author has estimated the potential infant dosage via breastfeeding would be ≤0.569 mg/kg/day (Chung 2002), providing a relative infant dose (RID) of 2.8%, based on an infant therapeutic dose of 20 mg/kg/day. In general, breastfeeding is considered acceptable when the RID is <10% (Anderson 2016; Ito 2000).
There is a case report of perforated pseudomembranous colitis in a breastfeeding infant whose mother was taking ciprofloxacin (Harmon 1992). In general, antibiotics that are present in breast milk may cause non-dose-related modification of bowel flora. Monitor infants for GI disturbances, such as thrush or diarrhea (WHO 2002).
The risk for transmission of plague (Y. pestis) via breast milk is considered low. Patients with pneumonic plague can breastfeed if both the mother and infant are receiving antibiotic treatment or the infant is receiving postexposure prophylaxis, considering the risk of exposure to the drug via breast milk. If the infant is not being treated, breast milk should be expressed for at least 48 hours of maternal antibiotic therapy to limit person-to-person contact with the infant. The expressed breast milk may be given to the infant. Once maternal clinical improvement is observed, direct breastfeeding may resume. Patients taking ciprofloxacin for the treatment of plague can decrease infant exposure via breast milk by feeding 3 to 4 hours after the dose (CDC [Nelson 2021]).
Recommendations for using ciprofloxacin in the management of B. anthracis in breastfeeding patients are the same as in pregnancy. Exposure to anthrax is not considered a contraindication to breastfeeding; however, if there are active cutaneous lesions on the breast, contact with the infant should be avoided and feeding from the affected breast should not occur until >48 hours of appropriate antibiotic therapy (CDC [Bower 2023]; Meaney-Delman 2014).
Alternative antibiotics are recommended in breastfeeding patients for the treatment of chancroid (CDC [Workowski 2021]) or meningococcal disease (CDC [Cohn 2013]).
In general, quinolone antibiotics should be avoided in breastfeeding patients if alternative agents are available (WHO 2002). Based on adverse outcomes observed in animal studies, the manufacturer recommends that breastfeeding be discontinued during therapy and for 2 days after the last ciprofloxacin dose if used for indications other than treating maternal B. anthracis. Mothers may express and discard milk during this time.
Food: May be taken with meals that contain dairy products (eg, milk, yogurt) or calcium-fortified products, but not with these products alone; separate administration of extended-release tablets [Canadian product] and calcium >800 mg by at least 2 hours
Caffeine: Patients consuming regular large quantities of caffeinated beverages may need to restrict caffeine intake if excessive cardiac or CNS stimulation occurs.
CBC, renal and hepatic function during prolonged therapy, altered mental status, signs and symptoms of tendinopathy (tendon pain, swelling, inflammation, or rupture) or peripheral neuropathy; signs and symptoms of disordered glucose regulation (especially in patients with diabetes mellitus); rash; signs and symptoms of hypersensitivity reaction.
Inhibits DNA-gyrase in susceptible organisms; inhibits relaxation of supercoiled DNA and promotes breakage of double-stranded DNA
Absorption: Oral: Well-absorbed; 500 mg orally every 12 hours produces an equivalent AUC to that produced by 400 mg IV over 60 minutes every 12 hours.
Distribution: Tissue concentrations often exceed serum concentrations, especially in kidneys, gallbladder, liver, lungs, gynecological tissue, and prostatic tissue.
Vd:
Neonates (GA: 23 to 42 weeks; PNA: 5 to 121 days): Median: 2.02 L/kg; range: 0.4 to 3.55 L/kg (Zhao 2014).
Adults: 2 to 3 L/kg (Canadian manufacturer's labeling); reported range: 1.74 to 5 L/kg (Vance-Bryan 1990).
Cerebrospinal fluid concentrations: Adolescents ≥16 years and Adults:
Noninflamed meninges: 2.9% to 40% (4 to 10 hours after dose) (Gogos 1991).
Inflamed meninges: 24.1% to 91.1% (1 to 9 hours after dose) (Gogos 1991).
Protein binding: 20% to 40%.
Metabolism: Partially hepatic; forms 4 metabolites (limited activity).
Bioavailability: Oral: Children: ~60% (oral suspension); Adults: 70%; younger cystic fibrosis patients have a lower bioavailability of 68% versus cystic fibrosis patients >13 years of age with bioavailability of 95%.
Half-life elimination:
Infants ≥4 months, Children, and Adolescents: 4.2 to 5.1 hours (Peltola 1998).
Children ≥5 years and Adolescents with cystic fibrosis: Mean range: 2.6 to 3.4 hours (Rubio 1997).
Adults: Normal renal function: 4 to 6 hours.
Time to peak: Oral:
IR tablet: 0.5 to 2 hours.
Excretion: Urine (35% to 70% as unchanged drug); feces (15% to 35%; <1% as unchanged drug).
Clearance: IV:
Neonates (GA: 23 to 42 weeks; PNA: 5 to 121 days): Median: 0.2 L/hour/kg; range: 0.04 to 0.81 L/hour/kg (Zhao 2014).
Infants, Children, and Adolescents: 0.48 L/hour/kg (Hirt 2021).
Children ≥5 years and Adolescents with cystic fibrosis: Mean range: 0.84 to 1.16 L/hour/kg (Rubio 1997).
Adults: 0.5 to 0.6 L/hour/kg.
Altered kidney function: The half-life is prolonged.
Older adult: Cmax increased 16% to 40%, AUC increased approximately 20% to 30%, and half-life increased approximately 20%.
Anti-infective considerations:
Parameters associated with efficacy:
Concentration dependent, associated with AUC24/minimum inhibitory concentration (MIC), goal: ≥125 (>80% clinical and microbiologic cures) (Forrest 1993); and Cmax(peak)/MIC ≥10 (bactericidal, resistance prevention) (Blaser 1987; Drusano 1993). Note: In critically ill patients, some experts recommend AUC24/MIC goal >125 to 250 and Cmax/MIC ≥12 (Abdul-Aziz 2020).
Expected drug exposure in patients with normal renal function:
AUC24:
Pediatric patients: 10 mg/kg/dose 3 times daily (multiple dose): IV:
Neonates and infants: 30.9 mg•hour/L.
Children <2 years of age: 27.8 mg•hour/L.
Children 2 to <6 years of age: 28.9 mg•hour/L.
Children 6 to <12 years of age: 20.4 mg•hour/L.
Adults (multiple dose):
500 mg twice daily: Oral: 27.4 mg•hour/L.
750 mg twice daily: Oral: 31.6 mg•hour/L.
400 mg every 12 hours: IV: 25.4 mg•hour/L.
400 mg every 8 hours: IV: 32.9 mg•hour/L.
Cmax (peak):
Pediatric patients: 10 mg/kg/dose 3 times daily (multiple dose): IV:
Neonates and infants: 2.8 mg/L.
Children <2 years of age: 3.6 mg/L.
Children 2 to <6 years of age: 2.7 mg/L.
Children 6 to <12 years of age: 2 mg/L.
Adults (multiple dose):
500 mg twice daily: Oral: 2.97 mg/L.
750 mg twice daily: Oral: 3.59 mg/L.
400 mg every 12 hours: IV: 4.56 mg/L.
400 mg every 8 hours: IV: 4.07 mg/L.
Postantibiotic effect: Bacterial killing continues after ciprofloxacin concentration falls below the MIC of targeted pathogen and varies based on the organism; generally, 1.5 to 3 hours (Craig 1991; Fuursted 1987; Kumar 1992).
